Q82.6
Congenital sacral dimple
Clinical Classification Guidelines
Inclusion Terms
- Parasacral dimple
Excludes Type 2
- pilonidal cyst with abscess (L05.01)
- pilonidal cyst without abscess (L05.91)
Medical Intelligence & Overview
A congenital sacral dimple, also known as a parasacral dimple, is a small indent that appears in the skin at the base of the back, near the sacrum. It is a common birth defect that often appears as a simple dimple but can sometimes be associated with underlying spinal abnormalities. Recognized under the ICD-10 code Q82.6, this condition typically presents in infants and young children and is usually detected during routine physical examinations. Most sacral dimples are harmless, but medical attention may be needed if other signs suggest deformities involving the spine or spinal cord.
Causes & Symptoms
Clinical Causes: Developmental anomalies during fetal growth affecting the skin and underlying structures Failure of proper fusion of the neural tube in early embryonic stages Genetic factors may play a role, but specific causes are often unknown Environmental influences during pregnancy are not well established but may contribute
Key Symptoms: A small, shallow skin depression located at the lower back, typically within the crease of the buttocks The dimple is usually less than a centimeter in diameter Possible presence of a tuft of hair, skin discoloration, or a sinus tract over the dimple Occasionally, associated anomalies such as lipomas, hemangiomas, or dermal sinuses In rare cases, signs of tethered spinal cord or other spinal cord abnormalities
Diagnostic & Treatment
Diagnosis Path: Diagnosis is primarily based on physical examination, with attention to the size, location, and appearance of the dimple. If there are additional skin abnormalities or signs of underlying issues, further imaging studies such as ultrasound, MRI, or CT scans may be ordered. These imaging techniques help evaluate the spinal cord, spinal canal, and any associated anomalies. Early detection and assessment are essential in determining whether intervention is necessary.
Treatment Protocols: Most sacral dimples are benign and require no treatment. Observation and reassurance are typically sufficient. However, if imaging studies reveal underlying spinal abnormalities, intervention may include surgical procedures to correct these issues. Close monitoring by healthcare professionals ensures that any associated conditions are managed appropriately. Routine follow-up might involve neurologic assessments to watch for signs of tethered cord syndrome or other complications.
Clinical Advice & FAQs
Billing Guidance
Is Q82.6 a billable ICD-10 code?
Yes, Q82.6 is a specific, billable code that can be used to indicate a diagnosis for reimbursement purposes.
Documentation
How do I report Q82.6?
Clinical documentation must specify the nature of Congenital sacral dimple and any associated comorbidities for accurate reporting.
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